A Travel Plan for GP Training

Listed below is some guidance as to what to consider doing with your trainee and when. This page is designed for Practice Managers, GP Trainers and any other member of staff involved in GP training. Please remember to revisit this page regularly to reassure yourself that you’re on track or to re-jig your memory. If you have any suggestions not listed on this page, please let me know ([email protected]). You may see the annotation (pf) amongst some of the things listed below. This is short for (personal favourite).

The first month is the busiest month. There is lots to do and get organised. However, take reassurance in the fact that things get generally easier from month 2 onwards. To make the first month a bit easier to understand, we have divided it into two sections: a) what you need to do in the first 2 weeks and b) what you need to do the the last 2 weeks. You need to make sure that the trainee has a period of time to ‘settle in’. They’ll need to get to know the whole practice team, get familiar with important policies and procedures and be aware of their personal responsibilities.

A SUMMARY FOR THE PRACTICE MANAGER

Do not book GP trainee in for their own surgeries

No daytime on-call duties

No signing of prescriptions

No telephone consultations

No visits (until start of week 2/3) – during week 1, the trainee should shadow visits with other doctors

Block one trainer surgery for a 1-1 “getting to know you session” with the new trainee

Book one session with the practice manager: tour of practice, protocols/policies, regulations, emergency equipment (as above)

Week 1: Book them in to observe a variety of consulting styles with different doctors

Week 2: Book ‘sitting with Nellie’ sessions with pharmacist, practice nurse, district nurse, health visitor, reception and the waiting room

-Learning needs – on the consultation(GP Trainer – Review trainee’s CV and see what posts they have already done and whether that is in keeping with their needs identified above. Devise a learning plan: how the various learning needs identified are going to be met?)[/fivecol_three_last]

If this is the first time the trainee is experiencing general practice, try and arrange for them to sit in with several different doctors during the first week rather than consulting on their own. This will expose them to a variety of consulting styles and demonstrate that there is no such thing as the ‘one and only’ consulting style. It will also help them discover their own personal style and start working on developing it.

Again, if this is the first time the trainee is experiencing general practice, the induction timetable should include sitting with with various members of the wider primary care health team (?perhaps in the second week) . Actually, you may still want to consider this for trainees who have done general practice before, but sometime ago. Below are some useful task sheets to help add structure ‘Sitting in with Nellie’ sessions in order to make greater educational impact. As with all task sheets, follow up via a discussion with the GP Trainer is essential (timetable this in if possible).

Finally, you need to book 2-4 sessions where the trainee recieves some initial training on the medical computer system (eg EMIS, Systm One). Below are some files that might help you. As a minimum, you should aim to cover:

A general overview of navigating around the medical record

How to add consultations

How to prescribe

How to do referrals and Choose & Book

How to use the internal email system

How to use practice notes (EMIS)

How to deal with medical letters (e.g. from the hospital)

How to handle lab results

They’ll also need 1-2 sessions where they can play around with a dummy patient.

Book patients at half hourly intervals (unless the trainee has already had previous training in a GP post: book at 20 min intervals. This 20-30 minute interval allows the trainee to gradually adapt from hospital medicine (where they’ve usually spent an hour or so taking a history and examination) to the general practice model of 10 minutes. It also gives them time to get used to the new computer medical system.

After the hustle and bussle of training month 1, relax: things get easier (generally). These are some considerations to bear in mind:

TITRATING SURGERIES

GP trainees ultimately need to get onto 10 minute appointments towards the end of their last post in general practice. This is quite a challenging task – in the hospital setting they had one hour or so to do this but all of a sudden, we’re asking them to cut this down drastically: clearly it is going to take time. To make this easier, GP trainees who have never been in a GP post before should really start off at 30 min appointments for each patient and end on 15-20 minutes after their first 6 months in a GP post. A GP trainee who has had previous experience of a GP post should be comfortable with starting at 20 minute appoints and end up on 10 minutes. However, all trainees are different as is their rate of progression. Some move steadily at the usual rate but others will need more time. Before stepping down the time, talk to the trainee and determine how comfortable they feel and whether their GP trainer feels they can handle the extra little pressure.

The length of consultation time for a typical trainee:

Months 1 & 2 : 30 mins

Months 3 & 4 : 20 mins

Months 5 & 6 : 15 mins

Months 7 & 8 : 15 mins

Months 9 & 10: 15-10 mins

Months 11 & 12: 10 mins

Please remember that this is guidance only; some trainees will need longer to adapt. Before shortening the interval, PLEASE consult both the trainee and trainer to ensure it is an appropriate time to move forwards. Trainees often feel apprehensive about the shortening of the interval and it is important to acknowledge this and empathise. Provide reassurance and tell them that this is a common feeling among GP trainees – and that they are not alone and that we can always move back a step if needs be.

CLINICAL SUPERVISION OF TRAINEES

GP trainees must be supervised at all times. In other words, someone has to be available for giving advice (and be available on site). This cannot be a locum GP. It has to be a GP partner or regular salaried GP. Someone should be available even when a trainee engages in baby clinic or child immunisations with the practice nurse.

WEEKLY TUTORIAL AND ASSESSMENT SLOTS

All GP trainees must be slotted in for a 3 hour weekly tutorial. The way you do this is up to you. 3 hours all in one go is probably a bit too much and perhaps two lots of 1.5 hour tutorials across the week (followed by a shortened surgery) would educationally fair better. What you cover in these tutorials is up to you. You might want to cover some clinical topics, significant events, problem cases, random cases, or something else. However, you must also reserve some of these slots for the mandatory MRCGP assessments that you are expected to carry out – namely, Case Based Discussions (CBDs) and Consultation Observation Tools (COTs). There is a MINIMUM number of each of these that need to be done. Usually this is 3 of each for an ST1/ST2 and 6 of each for an ST3 – but please remember that these are MINIMUMS and you should be aiming to do a lot more. If this minimum number is not achieved, a trainee can be asked to repeat an ST year – in other words, the consequences are big! In my practice the way I ensure that these assessments happen in an effortless way is to schedule a Monday 1.5h tutorial dedicated to doing COTs and a Weds 1.5h tutorial dedicated to doing CBDs. That doesn’t mean I always do COTs on a Monday and CBDs on a Weds – that’s just to mark their default position. We might occasionally veer off and do a Random Case Analysis or a review of significant events and sometimes even a clinical topic. I probably stick to doing a COT and CBD on their allocated days around 60-70% of the time. In this way, I don’t have to count numbers – I know we will end up doing lots more than the stipulated minimums. Remember: in a 6 month period, there are 26 weeks. During at least 6 of those weeks, you wont be doing a tutorial with the trainee – either they will be away on annual leave or you will be.

SCHEDULING VIDEO SURGERIES

The Consultation Observation Tool is a method of assessing a GP trainee’s consultation skills by reviewing video recordings of their consultations. Therefore, they need one or two regular surgery slot per week in which to record their consultations.

Practice Managers

Ask the trainee which days they would like to video on.

Video surgeries should certainly be in place by month 2. Mark these surgeries on the computer’s appointment system as video surgeries and remember to ensure that they are always booked at 20 minute intervals (unless the trainee is currently consulting longer).

Also go through with them the protocol for video surgeries – things like letting reception staff know so that they can tell patients, how to collect consent and so on. Consent is required of every patient that is video’d. Reception staff need to be explicitly trained in the art of obtaining consent. Consent forms have to be kept by the trainee until they finish training.

Sometimes, GP trainees can be very apprehensive about doing video surgeries and many don’t like the idea of doing them. It’s not surprising as for many of them it is a new experience. During these sessions, we’re also analysing their day-to-day performance behaviour – how would you feel? Therefore, it’s important for you to show some empathy and acknowledgement in this regard.

To help them settle in, reassure them that their feelings are normal and widespread among new GP trainees. Explore their anxieties and fears – try and alleviate them. Emphasise the formative nature of the feedback and the supportive climate in which this will be given. It might be worth you (the GP Trainer) showing a (non-perfect) video of yourself and analysing that – emphasising how no one is perfect and that even you can be taught a thing or two. Click here to read more about Video allergy

SIT AND SWAP SURGERIES

Sit and Swap surgeries, where the GP Trainer and trainee take it in turns to see patients, is one of the best ways of helping trainees acquire communication skills. The GP trainee has a go at some of the skills, whilst the GP trainer demonstrates and role models consultation behaviour.

I would suggest that the Practice Manager schedules regular Sit and Swap surgeries – at least one per month THROUGHOUT THE ENTIRE TRAINING PERIOD. Patients need to be booked in at 20 minute intervals. Just book them into one surgery (perhaps the trainee’s) and let the Trainer and trainee decide how they want to split seeing them.

Sit and Swap surgeries should be provided for trainees at all stages, not just ST1s. ST3s have consultation learning needs too – no matter how good they are.

Trainer – remember that some COTs can be carried out on directly observed consultations (no more than one in any one surgery).

Trainees may identify learning needs in very specific clinical domains. Things like experience in Drugs & Alcohol, Psychiatry, Dermatology and so on. Experience in some of these, like Asthma, can be provided by your practice. However, others like Dermatology might prove difficult. In such situations, encourage the trainee to find out where they might gain experience in the particular clinical domain they have identified. It might be a local GPwSI service in Dermatology held at a practice down the road from you.

Trainers – Clearly, the number and types of clinics they wish to attend needs to be in keeping with whether it will provide useful experience for the day to day job of being a GP. So for instance, a trainee who wants more experience of the asthma clinic run by the nurses might want to go to 2-3 sessions to get a better flavour. Attending more is unlikely to give added benefit and attending less may not give enough.

Practice Managers – Of course, releasing them has to be balanced against service provision back in the surgery. There is no point in doing a GP post if the trainee spends 3/4 of their time attending clinics and 1/4 of their time seeing patients in the surgery! If you have any concerns about this balance, please talk to the GP Trainer – they’re probably unaware. Otherwise, please try and cater for such requests to go elsewhere.

TELEPHONE CONSULTATIONS

Practice Managers – Consulting on the telephone is a skill in its own right and takes a while to develop. A new GP trainee usually has lots of things to get to grips with – the computer system, protocols, clinical stuff, communication skills and so on. It would be unfair to throw them at the deep end and get them to cope with telephone consultations too. It is suggested that the trainee is not given telephone consultations until after they have had time to adjust; usually at the 3 month stage. When you do put them down for telephone consultations: PLEASE tell both the GP Trainer and the trainee. Other than being courteous and good practice, it will signpost to the GP Trainer to provide a tutorial on ‘telephone consultation skills’.

Practice Managers – Again, putting on-call onto the new trainee within the first 3 months whilst they are still settling in is a no no. In fact, many practices don’t allocate any on-call duty sessions to trainees in their ST1 year because they simply have too much to contend with. Some don’t even allocate sessions during the first 6 month post of ST3 for the same reason. However, a GP trainee should be engaging in on-call duty sessions by the time they start ST3. How you actually decide really depends on the rate of progression of your trainee. Clearly, they need to be comfortable at doing it well in advance of the completion date for their training.

SIGNING PRESCRIPTIONS

Trainees may sign repeat prescriptions as soon as they start general practice. Again, it’s probably best they start doing this only after a period of adequately settling in. Perhaps from month 3 onwards. The GP Trainer and trainee should engage in a tutorial about repeat prescribing and what’s involved in a medication review prior to this.

Some non-trainer doctors in some practices moan about the proportion of time the GP Trainer actually spends on seeing patients (because of all this protected training time). If you sense any of this, don’t ignore it. Raise the issue and discuss it at a practice meeting. Remind them (especially if you’re a part-time GP with a full time trainee) how you are actually seeing more patients with combined forces than if you were operating alone. Remind them of the extra pair of hands to do home visits or help out on a particularly busy day. Remind them of the liveliness and joy trainees bring to the practice. Re-evaluate and re-establish your practice’s ethos towards training by gently re-engaging them (rather than being aggressively passionate). Click here to read about the advantages of becoming a training practice.

It’s also worthwhile trying hard to get the practice to see GP training as a practice activity rather than a Trainer-only activity. To do this requires engaging them and getting them to do some of the pleasurable things in GP training like doing clinical tutorials, debriefing trainees, clinically supervising them and so on. In this way, they too will feel the energy and dynamism that trainees bring to one’s working life. Also, try and put a training item or update onto the agenda at most practice meetings (even if it is just for information giving). Try and get discussions going and thereby making the rest of your team feel a core part of GP training. And finally, try and get your Practice Manager to share the same passion as you have for GP training. If anyone can make something happen smoothly – it’s the Practice Manager!

In addition to COT and CBD, are you doing Random Case Analyses, Problem Cases and using other methods to look at video (Gask’s PBI, ALOBA, Pendleton)? Also check to see if debriefing is happening after surgeries.

It’s important to ask your trainee to evaluate the training being provided by you and your practice. Review and reflect on the training you are providing: how can you make it better the next time round?

I often delegate this to the trainee in question (and combine it with the next trainee’s welcoming do). The whole practice team should be invited to this to say their goodbyes. Of course, this could prove expensive for the practice if they decide to pay for the meal. But it needn’t be that way: the practice might consider a £5-10 contribution per head a more affordable way of doing it. The leaving do also forms the basis of a ‘social’ for the practice team to help them strengthen bonds again.

GET THEM A LEAVING CARD

And get everyone to sign it (not just the doctors). It’s good practice to ask contributors to write down one thing they liked or will miss about the trainee (often a good way of feeding back on positive behaviour that the trainee will be encouraged to maintain). You might want to consider printing the following message and enclosing it with the leaving card (it’s something my trainer gave me and I have found it helpful ever since):

It’s likely that other group members (like the admin and nursing staff) will have bought the trainee their own card and personal gift. it’s also likely that some members would like to express some farewell wishes. The ideal way to do this is at a ‘leaving’ lunchtime break (or even the leaving do). Don’t do a quick 5 minute thing over lunch which fails to have impact – build in a hour of protected time or so.

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